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WE HAVE MADE THE PROCESS AS EASY AND CONVENIENT AS POSSIBLE.
APPLY FOR YOUR FREE MEDICATIONS IN JUST 4 EASY STEPS...
Locate the medication(s) you wish to apply for below:
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Click on the icon below to Download our Patient Assistance Application Forms:
DOWNLOAD PATIENT FORMS
The New Patient Forms are in PDF format and requires Adobe Acrobat Reader 4.0 or greater to open it. If you do not already have the latest version on Adobe Acrobat Reader, download it free from
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Fax the signed and completed forms to
888.879.0029
Pay first month’s fee of $59.95 + $20.00 application fee ($79.95 total).
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